Corrective Action Plans

Finding 502597 (2023-003)

Significant Deficiency 2023

Family Service and Guidance Center of Topeka, Inc.

KS

Allowable Costs / Cost Principles

Comments on the Finding Recommendation The Center experienced unusual staff shortage which did not allow the necessary review of journal entries and grant reconciliations. Action Taken A grant procedure will be implemented that has guidance on the review of journal entries each month and a review o...

Comments on the Finding Recommendation The Center experienced unusual staff shortage which did not allow the necessary review of journal entries and grant reconciliations. Action Taken A grant procedure will be implemented that has guidance on the review of journal entries each month and a review of grant reconciliations before grant reports are submitted to the funding source.

View Audit 324583

Finding 502592 (2023-002)

Significant Deficiency 2023

Family Service and Guidance Center of Topeka, Inc.

KS

Allowable Costs / Cost Principles

Comments on the Finding Recommendation Staff at the Center did not have knowledge of the rule on the 10% de minimis indirect cost rate. Action Taken Center staff involved in writing grant proposals and grant budgets and staff responsible for grant reporting will be trained on the rules regarding th...

Comments on the Finding Recommendation Staff at the Center did not have knowledge of the rule on the 10% de minimis indirect cost rate. Action Taken Center staff involved in writing grant proposals and grant budgets and staff responsible for grant reporting will be trained on the rules regarding the 10% de minimis indirect cost rate.

View Audit 324583

Finding 502587 (2023-001)

Significant Deficiency 2023

Family Service and Guidance Center of Topeka, Inc.

KS

Reporting Internal Control / Segregation of Duties

Comments on the Finding Recommendation The Center experienced unusual and extensive staff shortages in the finance department in the reporting period. The Center does not expect these circumstances to be repeated, but will implement a policy that designates 2 staff/positions to monitor grant report ...

Comments on the Finding Recommendation The Center experienced unusual and extensive staff shortages in the finance department in the reporting period. The Center does not expect these circumstances to be repeated, but will implement a policy that designates 2 staff/positions to monitor grant report deadlines. Action Taken The Center has a Policy for Grant Reporting that designates the staff responsible for tracking grant deadlines. The policy will be updated so that multiple staff/positions are listed as being responsible for grant report deadlines.

View Audit 324583

Finding 502578 (2023-008)

Material Weakness 2023

Okanogan Behavioral Healthcare

WA

Allowable Costs / Cost Principles Eligibility Material Weakness

Action taken in response to finding: OBHC implemented new payroll software in March 2023. During FY24, staff were trained to directly allocate their time to programs in their electronic timecard. Effective Feb 2024, time and effort reporting was used to allocate salaries to the SOR program. Additio...

Action taken in response to finding: OBHC implemented new payroll software in March 2023. During FY24, staff were trained to directly allocate their time to programs in their electronic timecard. Effective Feb 2024, time and effort reporting was used to allocate salaries to the SOR program. Additionally, the OBHC team is currently working with the HCA in restructuring the rate schedule to incorporate the payroll costs into the direct service rates for the SOR/SABG grants. This effectively removes this issue going forward in FY25 once approved by the HCA. Name(s) of the contact person(s) responsible for corrective action: Patty Brandt Planned completion date for corrective action plan: Feb 2024 & Sep 2024

View Audit 324580

Finding 502577 (2023-007)

Significant Deficiency 2023

Okanogan Behavioral Healthcare

WA

Cash Management Allowable Costs / Cost Principles Significant Deficiency

Action taken in response to finding: The grant biller performs additional review of grant billings for accuracy. In addition, the new CFO reviews and approves at a detailed level the grant billing. Name(s) of the contact person(s) responsible for corrective action: Patty Brandt Planned completion ...

Action taken in response to finding: The grant biller performs additional review of grant billings for accuracy. In addition, the new CFO reviews and approves at a detailed level the grant billing. Name(s) of the contact person(s) responsible for corrective action: Patty Brandt Planned completion date for corrective action plan: August 31, 2024

View Audit 324580

Finding 502576 (2023-006)

Material Weakness 2023

Okanogan Behavioral Healthcare

WA

Allowable Costs / Cost Principles Material Weakness

Action taken in response to finding: OBHC implemented new payroll software in March 2023. During FY24, staff were trained to directly allocate their time to programs in their electronic timecard. Effective Feb 2024, time and effort reporting was used to allocate salaries to the SABG program. Additi...

Action taken in response to finding: OBHC implemented new payroll software in March 2023. During FY24, staff were trained to directly allocate their time to programs in their electronic timecard. Effective Feb 2024, time and effort reporting was used to allocate salaries to the SABG program. Additionally, the OBHC team is currently working with the HCA in restructuring the rate schedule to incorporate the payroll costs into the direct service rates for the SOR/SABG grants. This effectively removes this issue going forward in FY25 once approved by the HCA. Name(s) of the contact person(s) responsible for corrective action: Patty Brandt Planned completion date for corrective action plan: Feb 2024 & Sep 2024

View Audit 324580

Finding 502575 (2023-005)

Significant Deficiency 2023

Okanogan Behavioral Healthcare

WA

Cash Management Allowable Costs / Cost Principles Period of Performance

Action taken in response to finding: The new CFO reviews and approves federal grant draw requests prior to the submission to the granting agency. Name(s) of the contact person(s) responsible for corrective action: Carrie Anthony Planned completion date for corrective action plan: August 31, 2024

View Audit 324580

Finding 502574 (2023-004)

Significant Deficiency 2023

Okanogan Behavioral Healthcare

WA

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Significant Deficiency

Action taken in response to finding: The program experienced transition in management and staff during FY23. The new Recovery Support Services staff are now fully trained and ensures expenditures are charged appropriately, approved by a knowledgeable supervisor, and supporting documentation is main...

Action taken in response to finding: The program experienced transition in management and staff during FY23. The new Recovery Support Services staff are now fully trained and ensures expenditures are charged appropriately, approved by a knowledgeable supervisor, and supporting documentation is maintained on file. Additionally, AP and Finance team review supporting documentation and ensure completeness. Name(s) of the contact person(s) responsible for corrective action: Floral Reed Planned completion date for corrective action plan: June 30, 2024

View Audit 324580

Finding 502573 (2023-003)

Significant Deficiency 2023

Okanogan Behavioral Healthcare

WA

Allowable Costs / Cost Principles Cash Management Period of Performance

Action taken in response to finding: The program experienced transition in management and staff during FY23. The new Recovery Support Services staff are now fully trained and ensures expenditures are incurred, charged appropriately and supporting documentation is maintained on file. Additionally, ...

Action taken in response to finding: The program experienced transition in management and staff during FY23. The new Recovery Support Services staff are now fully trained and ensures expenditures are incurred, charged appropriately and supporting documentation is maintained on file. Additionally, AP and Finance team review supporting documentation and ensure completeness. Name(s) of the contact person(s) responsible for corrective action: Floral Reed Planned completion date for corrective action plan: June 30, 2024

View Audit 324580

Finding 502572 (2023-002)

Significant Deficiency 2023

Okanogan Behavioral Healthcare

WA

Cash Management Significant Deficiency

Action taken in response to finding: The new CFO reviews and approves federal grant draw requests prior to the submission to the granting agency. Name(s) of the contact person(s) responsible for corrective action: Carrie Anthony Planned completion date for corrective action plan: August 31, 2024

View Audit 324580

Finding 502571 (2023-001)

Significant Deficiency 2023

Okanogan Behavioral Healthcare

WA

Allowable Costs / Cost Principles Period of Performance Significant Deficiency

Action taken in response to finding: The Finance team corrected their processes to ensure proper recording of payroll costs during the time of the FY22 Audit procedures; however, the changes were made to subsequent months and previously submitted months were not retroactively corrected. Additionall...

Action taken in response to finding: The Finance team corrected their processes to ensure proper recording of payroll costs during the time of the FY22 Audit procedures; however, the changes were made to subsequent months and previously submitted months were not retroactively corrected. Additionally, the OBHC team is currently working with the HCA in restructuring the rate schedule to incorporate the payroll costs into the direct service rates for the SOR/SABG grants. This effectively removes this issue going forward in FY25 once approved by the HCA. Name(s) of the contact person(s) responsible for corrective action: Carrie Anthony Planned completion date for corrective action plan: Sep 2023 & New rates: Sep 30, 2024

View Audit 324580

Finding 502566 (2023-001)

Material Weakness 2023

New York College of Traditional Chinese Medicine

NY

Reporting Special Tests & Provisions Student Financial Aid

Finding 2023-001: Inaccurate and Untimely Enrollment Status Reporting Comments on Finding and Recommendation(s): Statement of Concurrence: We concur with the finding of inaccurate and untimely reporting of enrollment status. The issue was due to human error from a previous employee who has been term...

Finding 2023-001: Inaccurate and Untimely Enrollment Status Reporting Comments on Finding and Recommendation(s): Statement of Concurrence: We concur with the finding of inaccurate and untimely reporting of enrollment status. The issue was due to human error from a previous employee who has been terminated as well as a misunderstanding of the policy. The transition period following the termination further compounded these issues. Actions Taken or Planned: 1. New Hire: We have already hired a new member for Financial Aid position since April 2023. This individual is responsible for ensuring the accuracy and timeliness of enrollment status reporting moving forward. 2. Staff Training: • All relevant personnel, including the newly hired staff, have been scheduled for ongoing training on financial aid compliance and the reporting process. • We will ensure that each employee is proficient in using the reporting systems (e.g., NSLDS, COD) and understands the required timelines for submission. 3. Process Review and Improvement: We are reviewing our existing processes to identify gaps and inefficiencies in the current reporting system. Once identified, these processes will be updated to ensure better data accuracy and timeliness. 4. Ongoing Monitoring and Compliance Audits: We will establish regular internal audits and monitoring protocols to ensure continuous compliance with reporting standards. Completion Date: Ongoing Dong-Hua Yang MD, PhD Title: Administrative Dean

View Audit 324573

Finding 502558 (2023-002)

Significant Deficiency 2023

Puerto Rico Health Insurance Administration

PR

Allowable Costs / Cost Principles Reporting

The PRHIA was proactive to ensure compliance in submitting the 2023 Single Audit Report by due date, maximizing the human resources available, in collaboration with auditors. The PRHIA expects to ensure compliance by submitting the 2023 Single Audit Report by its due date.

View Audit 324551

Finding 502556 (2023-001)

Material Weakness 2023

Puerto Rico Health Insurance Administration

PR

Internal Control / Segregation of Duties

ASES contracted a Cybersecurity expert to review the Disaster Recovery Plan (DRP) and a Business Impact Analysis was completed to acquire space within the AZURE cloud with the approval of the Puerto Rico Innovation and Technology Service (PRITS). The strategy of protection and alternate space was d...

ASES contracted a Cybersecurity expert to review the Disaster Recovery Plan (DRP) and a Business Impact Analysis was completed to acquire space within the AZURE cloud with the approval of the Puerto Rico Innovation and Technology Service (PRITS). The strategy of protection and alternate space was designed to work on ASES applications and documents in case of a disaster. ASES already has a virtual RED environment where the resources are being replicated for users and area documentation and eventually the servers will be replicated in the AZURE space. Additionally, an internal Risk Assessment was performed that helped identify and remedy the vulnerabilities in the agency. It was prepared by the Information Systems Security Administrator, evaluated by the personnel hired at the executive level and signed in acceptance of the exercise carried out. As a result, the DRP was updated based on departmental needs and the current capabilities of the agency's information systems. ASES also implemented the use of OneDrive tools for users to save their documents in this application and SharePoint for departmental files and documents.

View Audit 324551

Finding 502544 (2023-003)

Significant Deficiency 2023

Brooklyn Bureau of Community Service Dba Brooklyn Community Services

NY

Reporting Significant Deficiency § 200.512

Finding 2023-03 Reporting – Data Collection Form and Reporting Package (Significant Deficiency) U.S. Department of Health and Human Services Community Services Block Grant (Federal Assistance Listing #93.569) Federal Award Numbers: 60204, 60215, 60225, and 60235 Federal Award Year: 2020-2023 R...

Finding 2023-03 Reporting – Data Collection Form and Reporting Package (Significant Deficiency) U.S. Department of Health and Human Services Community Services Block Grant (Federal Assistance Listing #93.569) Federal Award Numbers: 60204, 60215, 60225, and 60235 Federal Award Year: 2020-2023 Responsible Officials Contact Information: 1) Monae Priolenau-Jones Telephone 718-310-5610, mpriolenau@wearebcs.org 2) Jodi Querbach Telephone 718-310-5600, X 1015 jquerbach@wearebcs.org View of Responsible Officials and Corrective Action Plan: Management agrees that the single audit reporting package was not submitted within the required timeframe due to key employee turnover coupled with staffing challenges subsequent to year end. In addition, BCS began a transition from one third-party external firm to another third-party firm in September of 2022. The former firm held the general ledger data for BCS and has been slow to turn it over in a manageable manner causing the delay in filing of the single audit report package. Dmitriy Goyzman (current Chief Financial Officer) was hired in December of 2022 and is actively in the process of hiring a new internal finance team. Back office finance department operations are currently filled by the second third-party external firm. In addition to the CFO, BCS has payroll, purchasing and 2 staff accountants and will have a Controller on staff by mid-June of 2023. Hiring of five additional positions for grants management will be completed in the Fall of 2023 replacing BDO personnel with in-house staff. In our new configuration, BCS will: 1) own its financial software and data, 2) be sufficiently staffed to run its day-to-day financial operations, 3) be able to support program operations in an efficient manner and 4) be able to respond and complete audits on time. The management will ensure that the single audit report package is submitted before the March 31, 2025 deadline. Pursuant to the action plan outlined in the response to Finding 2023 001, the audited financial statements will be issued by November 30th, 2024. Immediately following, the finance team will turn their attention to the reports required by the Uniform Guidance and the Federal Form 990 with a goal of completing fiscal 2024 reporting requirement by January 2025. Recommendation: We recommend that BCS enhance its closing and reporting process to ensure the reports required by the Uniform Guidance is submitted by the aforementioned deadline.

View Audit 324549

Finding 502543 (2023-002)

None 2023

Brooklyn Bureau of Community Service Dba Brooklyn Community Services

NY

Subrecipient Monitoring Special Tests & Provisions

Finding 2023-002 Evaluation of federal compliance requirements when receiving subawards U.S. Department of Health and Human Services Community Services Block Grant (Federal Assistance Listing #93.569) Federal Award Numbers: 60204, 60215, 60225, and 60235 Federal Award Year: 2020-2023 Responsible O...

Finding 2023-002 Evaluation of federal compliance requirements when receiving subawards U.S. Department of Health and Human Services Community Services Block Grant (Federal Assistance Listing #93.569) Federal Award Numbers: 60204, 60215, 60225, and 60235 Federal Award Year: 2020-2023 Responsible Officials Contact Information: 1) Monae Priolenau-Jones Telephone 718-310-5610, mpriolenau@wearebcs.org 2) Jodi Querbach Telephone 718-310-5600, X 1015 jquerbach@wearebcs.org View of Responsible Officials and Corrective Action Plan: BCS was notified that we must administer the Community Services Block grant program through a tripartite board for our fatherhood program. BCS has since received an advisory opinion from an Assistant General Counsel of the Department of Youth and Community Development stating that “the tripartite board requirement applies to local community action agencies [CAA], which is DYCD, not sub recipients...” Accordingly, as a sub recipient, BCS is not responsible for the implementation of the tripartite advisory committee. Moreover, the creation of the tripartite advisory committee would require BCS to have a board of directors which would include elected officials. It is in the sole discretion of BCS to decide whether to include an elected official on the board, as being mandated to do so by this directive may pose a potential conflict for BCS that may run contrary to state and federal laws. The BCS Board and Executive Management have implemented a comprehensive plan to complete the fiscal 2024 financial close and issue audited financial statements by November 30th, 2024. This marks an eight-month acceleration compared to fiscal 2023. This will be accomplished through better utilization of the general ledger system, a sequenced workplan with deadlines, and by assigning all tasks to specific staff. Step two of the same plan will deliver monthly financial statements within 21 days of the month end, starting with November 2024. These statements will be reviewed by Executive Management

View Audit 324549

Finding 502532 (2023-002)

None 2023

Cuyuna Regional Medical Center

MN

Reporting Subrecipient Monitoring § 200.512

Identifying Number: 2023-002 Finding: Late Issuance of 2023 Single Audit Reporting Package Corrective Actions Taken or Planned: The Center will issue the single audit reporting package after the external audit is completed. Our single audit was performed timely, however, the purposeful delay of the ...

Identifying Number: 2023-002 Finding: Late Issuance of 2023 Single Audit Reporting Package Corrective Actions Taken or Planned: The Center will issue the single audit reporting package after the external audit is completed. Our single audit was performed timely, however, the purposeful delay of the external audit impacted our ability to finalize. Contact Persons(s) Responsible for Correction Action: Katie Berg, CFO Completion Date: October 30, 2024

View Audit 324527

Finding 502529 (2023-003)

None 2023

Community Health Awareness Group

MI

§ 200.512

CHAG management has worked with the audit team to create a time line for the next audit cycle to ensure that all future audits are completed and filed not later than the 30th of April.

View Audit 324522

Finding 502525 (2023-002)

Material Weakness 2023

Iowa Falls Community School District

IA

Internal Control / Segregation of Duties

We will continue to review our control procedures to ensure we achieve the maximum internal control possible under the circumstances.

View Audit 324505

Finding 502505 (2023-004)

Significant Deficiency 2023

Catholic Charities West Michigan

MI

Reporting Significant Deficiency

Action Taken: Timely reporting as well as documented approvals are very important to Catholic Charities West Michigan and we agree that we must demonstrate that proper reviews or reports have occurred. We have implemented a process including monthly meetings with the Program Manager and the Finance...

Action Taken: Timely reporting as well as documented approvals are very important to Catholic Charities West Michigan and we agree that we must demonstrate that proper reviews or reports have occurred. We have implemented a process including monthly meetings with the Program Manager and the Finance Accountant to review activity and close the month. All reporting is now filed timely with proper documented review.

View Audit 324497

Finding 502502 (2023-003)

Material Weakness 2023

Catholic Charities West Michigan

MI

Questioned Costs Special Tests & Provisions Eligibility

Action Taken: The Senior Programs have undergone significant improvements in the last 6 months following an audit by the federal funder which resulted in a corrective action plan (CAP) and a repayment of $54,228. Plans were implemented during the spring of 2024 in response to the CAP which resulted...

Action Taken: The Senior Programs have undergone significant improvements in the last 6 months following an audit by the federal funder which resulted in a corrective action plan (CAP) and a repayment of $54,228. Plans were implemented during the spring of 2024 in response to the CAP which resulted in an overhaul of the processes in place to properly develop the volunteer checklists and assure all records for staff and volunteers are now compliant. Our Quality and Compliance and Finance team worked closely with the new Program Manager to assure that we will be fully compliant and remain so.

View Audit 324497 Questioned Costs: $1

Finding 502499 (2023-002)

Significant Deficiency 2023

Catholic Charities West Michigan

MI

Reporting Cash Management Significant Deficiency

Action Taken: Modifications of the Administrative Financial Management and Cash Management policies will be made to further address concerns identified in the Single Audit. In addition, the reconciliation process will be reviewed and improved to assure timely preparation of the SEFA. CCWM will rec...

Action Taken: Modifications of the Administrative Financial Management and Cash Management policies will be made to further address concerns identified in the Single Audit. In addition, the reconciliation process will be reviewed and improved to assure timely preparation of the SEFA. CCWM will reconcile federal programs to the passthrough agencies 9 months into the fiscal year at a minimum as part of the preparation of the SEFA report.

View Audit 324497

Finding 502478 (2023-003)

Significant Deficiency 2023

Guam Memorial Hospital Authority

GU

Procurement, Suspension & Debarment § 200.214

Views of Auditee and Planned Corrective Actions: Starting in April 2024, GMHA incorporated the Certificate Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion for Covered Contracts and Grants in all of its Invitation for Bids and Request for Proposals. Proposed Complet...

Views of Auditee and Planned Corrective Actions: Starting in April 2024, GMHA incorporated the Certificate Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion for Covered Contracts and Grants in all of its Invitation for Bids and Request for Proposals. Proposed Completion Date: Completed. Name of Contact Person: Yukari Hechanova, Chief Financial Officer

View Audit 324486

Finding 502477 (2023-002)

Material Weakness 2023

Guam Memorial Hospital Authority

GU

Allowable Costs / Cost Principles § 200.439

Views of Auditee and Planned Corrective Actions: Being in constant financial constraints facing vendor delivery holds and discontinuing critical services, the Department of Administration (DOA) directly paid certain GMHA vendors. With the urgency of need and insufficient information about the sou...

Views of Auditee and Planned Corrective Actions: Being in constant financial constraints facing vendor delivery holds and discontinuing critical services, the Department of Administration (DOA) directly paid certain GMHA vendors. With the urgency of need and insufficient information about the source of funds’ eligibility requirements, an amount owed for an equipment purchase was included in the invoices DOA paid. Moving forward, GMHA will be more proactive in obtaining grants’ eligibility requirements to ensure compliance. In addition, accounting personnel directly involved in reviewing and approving federal grant expenditures will continuously participate in training related to Uniform Guidance Updates. On August 28, 2024, the Chief Financial Officer and the General Accounting Supervisor attended an OMB Uniform Guidance Updates training. Proposed Completion Date: Completed. Name of Contact Person: Yukari Hechanova, Chief Financial Officer

View Audit 324486

Finding 502476 (2023-001)

Material Weakness 2023

United Piedmont Center for Educational Excellence, INC

NC

Cash Management Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.305

To address these issues - UPCEE has hired a new Contract Manager (that comes highly recommended and has worked successfully with other TRIO programs) who will continue to do the following: • Oversee office management processes, budgets, and enhance our current way of working with federal timelines....

To address these issues - UPCEE has hired a new Contract Manager (that comes highly recommended and has worked successfully with other TRIO programs) who will continue to do the following: • Oversee office management processes, budgets, and enhance our current way of working with federal timelines. • Ensure billings are kept timely and entered in the financial system for QuickBooks Online and now updates data entry after each completed month. These changes allow for the immediate completion and availability of data to be used for 990 completion and audit processing. • Work in tandem with the UPCEE Executive Director to ensure these tasks are done. With the implementation of these new processes, UPCEE feels very confident that this will prevent any further need for risk management.

View Audit 324484

Corrective Action Plans

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